Provider Demographics
NPI:1558859710
Name:INTEGRAL PHARMACY, LLC
Entity Type:Organization
Organization Name:INTEGRAL PHARMACY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:RODRIGUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:505-862-9082
Mailing Address - Street 1:224 CRESTWOOD CT
Mailing Address - Street 2:
Mailing Address - City:GALLUP
Mailing Address - State:NM
Mailing Address - Zip Code:87301-7120
Mailing Address - Country:US
Mailing Address - Phone:505-235-2810
Mailing Address - Fax:
Practice Address - Street 1:109 S SECOND ST
Practice Address - Street 2:
Practice Address - City:GALLUP
Practice Address - State:NM
Practice Address - Zip Code:87301-6219
Practice Address - Country:US
Practice Address - Phone:505-862-9082
Practice Address - Fax:844-492-1938
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-24
Last Update Date:2018-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPH000046163336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy